Hillel D. Braude, a physician and a philosopher, has written an important, albeit dense and narrowly circumscribed, study. While “Intuition in Medicine” is the main title, the subtitle, “A Philosophical Defense of Clinical Reasoning” is a more accurate description of the book, which originated as a doctoral dissertation. While some of the prose will appeal only to specialists, there are important and thoughtful analyses of such topics as Evidence-Based Medicine, modern dehumanized medicine, the relation of beneficence and automony, and principalist ethics in general. Throughout, intuition is narrowly conceived and in the service of clinical reasoning, as it applies to standard, Western physicians and not to other healers (or nurses), and the emphasis is on interventive medicine to cure illness and relieve suffering more than on health promotion.

Braude writes in the introduction that intuition has long been understood to be “a direct perception of things,” but he resists a more precise definition: “Rather than defining and using a single concept of intuition—philosophical, practical, or neuroscientific—this study examines intuition as it occurs at different levels and in different contexts of clinical reasoning” (xviii). Eight chapters explore these different levels in such topics as moral intuitionism, Aristotle’s phronesis (or practical reason), the rise of statistics (a basis for Evidence-Based Medicine), and C. S. Peirce’s notion of abduction. Braude’s careful analysis traces historical and theoretical developments in analytic philosophy and how these may be applied to clinical reasoning. He uses an impressive range of thinkers: Achenwall, Albert, Allan, Andre, Ashcroft, Aristotle, Bacon, Barrow, Barton, Beauchamp, Bergson, Bernard, Bichat, Black, Bottero, Bourdieu, Brody, Browne—just to take names headed by A or B.
Throughout, Braude puts in dialectic two poles of a spectrum
arguing that they both have contributions to make. He believes that between
them is an “ethical space,” where discoveries and applications can be
made.
One pole, which he clearly favors, includes the following
qualities: Aristotelian practical reasoning, naturalist
approaches, primacy of beneficence, fact and value joined, case-based,
individual patients, narrative experience, anthropocentric focus, and tacit/organic
knowledge (Polanyi). The other pole, less desirable, includes Kantian abstraction, nonnaturalist
approaches, primacy of autonomy, fact and value separated, Evidence-Based
Medicine, large groups of patients, statistical correlations,
mechanist/positivist foci, and Dualism (Descartes).

Braude believes intuition is a cognitive process but has other dimension, the corporeal and the social. While these provide a grounding, intuition for him is generally rational. He also argues for medical care at the personal, face-to-face level, not through applications of algorithms. A brief conclusion, “Medical Ethics beyond Ontology” clarifies some of the arguments and sketches some valuable notions from Husserl and Levinas. He writes “intuition . . . does appear to be fundamental for human judgment” because “an intuition faculty” can “extract universals from the particular” (p. 170). Drawing on Husserl, he defines phenomenological intuition as “the primary means through which objects are presented to consciousness.” This affirmation includes the basic human, which is also the focus for medicine. For Levinas (and my summary is much too brief), “interhuman solidarity” is a source for medical care, a form of responsibility that is different from Foucaultian power relationships, ethical rules and priniciples, or “an uncritical acceptance of medical authority” (p. 177).

Leonardo
da Vinci – the name alone evokes images of an artistic virtuoso, the
Renaissance man, the mind behind the Mona
Lisa. Though known best as an artist, his work extended beyond paintings
into a myriad of disciplines, with notebook entries documenting his studies of
optics, bird flight, comparative anatomy, hydraulics, and countless others. And
yet what has been obscured by the shadow cast by his prolific career are the
details of how a young man from a town called Vinci became Leonardo da Vinci.
What did he do every day? What did he eat? Who were his friends? Did he even
have any? We tend to immortalize Leonardo as a god, and yet he was human after
all, not unlike the rest of us. This realization should encourage us to study
one of history’s most celebrated humans, and see if we ourselves might be able unlock
our own inner genius.

Walter
Isaacson aids us in this study with his thoroughly researched biography of
Leonardo da Vinci. He adds this to his growing portfolio of biographies of
history’s great minds, including Benjamin Franklin, Albert Einstein, and Steve
Jobs. In this most recent biography, Isaacson takes us through the life and
times of Leonardo, highlighting milestones of his career, while also
underscoring some of the seemingly trivial habits that were signatures of
Leonardo’s personality and worldview.
Born of
illegitimacy and openly gay, Leonardo was no stranger to defying convention. In
fact, many of his grandest discoveries were a result of his willingness to
challenge commonly accepted wisdom. Yet his greatest asset was his relentless
curiosity and unquenchable thirst for knowledge, a recurring theme of
Isaacson’s biography and of Leonardo’s life. Intertwined with this curiosity
was his tendency to draw connections across disciplines, blurring the lines
between art and science. Everything that Leonardo produced – whether his sketches
of war machines, his treatises on anatomy, or his timeless portraits – was a
manifestation of his desire for unifying knowledge.

Intern, Maggie Altman, begins her postgraduate training in a large Texas hospital where a new computerized system has been implemented to improve service. She pours heart and soul into her work, but her admissions always seem to be the sickest patients who keep dying, sometimes inexplicably. Maggie becomes suspicious of her colleagues and of Dr. Milton Silber, an irrascible, retired clinician with no fondness for the new technology. Silber also happens to be a financial genius. Overhearing conversations and finding puzzling papers, Maggie imagines a scam, in which her supervisors may be eliminating dying patients to reduce costs, improve statistics, and siphon funds to their own pockets.

The bad outcomes for Maggie's patients are noticed and criticized, and she is pressured to drop out, switch hospitals, or go back into research. She senses that the perpetrators are aware of her suspicions and send her the worst patients in an effort to eliminate her. She trusts no one. These worries are compounded by her own illness and her accidental discovery in the morgue of a traffic in unclaimed bodies. With the help of excellent clinical skills, true friends, Dr. Silber, and a new love interest who is a budding financial genius, she survives physical and emotional violence and solves the mystery of patient homicides, poisonings, and fraud.

Dr. Monika Renz’s work with dying patients is unusual if not
unique in the way she appropriates and applies insights from Jungian depth
psychology, practices available in patients’ faith traditions, and musically
guided meditation to invite and support the spiritual experiences that so often
come, bidden or unbidden, near the end of life.
An experienced oncologist, Dr. Renz offers carefully amassed data to support
her advocacy of focused practices of spiritual care as a dimension of
palliative care, but is also quite comfortable with the fact that “neither the
frequency nor the visible effects of experiences of the transcendent prove that
such experience is an expression of grace” because “unverifiability is
intrinsic to grace.” Still, her long
experience leads her to assert not only that “grace” can be a useful,
practical, operative word for what professional caregivers may witness and
mediate but also that affirmation and support of patients’ spiritual,
religious, or transcendent experiences in the course of dying can amplify and
multiply moments of grace, which manifest as sudden, deep peace in the very
midst of pain, profound acceptance, openness to reconciliations, or significant
awakenings from torpor that allow needed moments of closure with loved ones. Describing herself as “an open-minded
religious person and a practicing Christian,” she reminds readers that God is a loanword, whose basic form in
Germanic was gaudam, a neutral
participle. Depending on the
Indo-Germanic root, the word means “the called upon” or “the one sacrificed to
. . . .” Openness to the divine in both
patients and caregivers, Dr. Renz argues, can and does make end-of-life care a
shared journey of discovery and offer everyone involved a valuable reminder that
medicine is practiced, always, at the threshold of mystery.

Victoria Sweet describes her training in medical school,
residency, and work in various clinics and hospitals. From all of these she
forms her own sense of what medical care should include: “Slow Medicine” that
uses, ironically, the best aspects of today’s “Fast” medicine.

Her dramatic “Introduction: Medicine Without a Soul” describes poor—even
dangerous—care given to her elderly father at a hospital. An experienced
physician, she calls Hospice and saves him from a “Death
Express” the hospital has “quality-assured” (pp. 6, 8).

The book continues with 16 chapters in chronological order. The first ten
describe Sweet from a late ‘60s Stanford undergrad and “a sort of hippie”
(p.14), next a learner of “facts” in preclinical studies at Harvard, plus the
clinical rotations (including Psychiatry, Internal Medicine, Pediatrics, and
electives), then an internship as a doctor and her work in various clinics and
hospitals. Throughout she’s collecting skills, concepts, even philosophies
(Jung, feminism, Chinese chi, value of stories). She also describes
particular patients important to her learning. She dislikes “just good enough”
medicine at the VA (p. 95), “unapologetic budgetarianism” (p 141), medicine
that is reductive and uncaring, and futile care for dying patients.
Halfway through, we find an “Intermission: In which Fast Medicine and Slow
Medicine Come Together.” With a year off, Sweet signs on as physician for a
trekking group headed for Nepal. Unexpectedly, she treats an Englishman in the
Himalayas. Returning home, she treats a man whose pulse is declining and rides
a helicopter with him to a hospital. She realizes that she can take on the full
responsibility of being a doctor, including when to use Fast medicine
and when to use Slow.

The following chapters deal with the 1980s emergence of AIDS, a hand injury to
Sweet (she sees herself as “a wounded healer,” p. 182), her new understanding
of medicine as “A Craft, A Science, and an Art” (Chapter 12) and conflicts between
medical care and economics-driven medicine (“checked boxes,” administrators,
quality assurance, even outright corruption). She scorns use of the
labels “health-care providers” and “health-care consumers” (p. 211) and
discovers Hildegard of Bingen’s medieval vision of medicine. She works for 20
years at Laguna Honda, the topic of her earlier book God’s Hotel(2012). Chapter 16 closes the book with “A Slow Medicine Manifesto.”

Sweet pays tribute to her teachers, both in a dedication to the book, and
throughout the pages: professors, preceptors, nurses—especially a series of
Irish Kathleens—and patients. There are some 20 case studies of patients
throughout the book, their medical dilemmas, their personalities, and Sweet’s Slow
Medicine that involves creating a healing relationship with them, finding the
right path for treatment, even watching and waiting.

In this follow-up to his masterful memoir Do No Harm, British neurosurgeon Henry Marsh must deal with old age and retirement after nearly four decades as a doctor. Stepping down engenders mixed feelings, and he confesses to "longing to retire, to escape all the human misery that I have had to witness for so many years, and yet dreading my departure as well" (p17).

Marsh keeps busy by spending time in Nepal training young doctors and operating. He also makes visits to the Ukraine to perform surgery and teach. He has a fondness for creating things and purchases a fixer upper cottage that he struggles to repair. Marsh recounts previous neurosurgical cases, mostly patients with brain tumors. He remembers the distress at being sued by patients. He reveals his own admission to a psychiatric hospital as a young man. Regrets, both personal and professional, are confessed.

This Side of Doctoring is
an anthology published in 2002 about the experiences of women in medicine. While
the essays span multiple centuries, most are from the past 50 years. They reflect
on a multitude of stages in the authors’ personal and professional lives. In
344 pages divided into twelve sections, including "Early Pioneers,"
"Life in the Trenches," and "Mothering and Doctoring," the
146 authors recount - in excerpts from published memoirs, previously published
and unpublished essays, poems and other writings, many of them composed solely
for this collection - what it was then and what it was in 2002 to be a woman
becoming a doctor in the U.S.. All but a handful of the authors are physicians
or surgeons. There is a heavy representation from institutions on both coasts, especially
the Northeast. Four men were invited to reflect on being married to physician
wives. There is one anonymous essay concerning sexual harassment and a final essay
from a mother and daughter, both physicians.Beginning with the first American female physicians in the
mid-19th century, like historic ground-breakers Elizabeth Blackwell and Mary
Putnam Jacobi, the anthology proceeds through the phases of medical school,
residency, early and mid-careers, up to reflections from older physicians on a
life spent in medicine. Many of the authors have names well known in the
medical humanities, including Marcia Angell, Leon Eisenberg, Perri Klass,
Danielle Ofri, Audrey Shafer, and Marjorie Spurrier Sirridge, to mention a
few.

The essays and poems and letters have, as a partial listing, the following
subjects: family influences in becoming a physician; professional friendships; marriage;
children and their impact on a woman’s career in medicine; the decision not to
have children; ill family members; illness as a physician; establishing one's
sexuality as a physician; struggles with male physicians and their egos;
mentors, both female and male; memorable patients (often terminal or dying);
the life of a wife-physician, or mother-physician; the guilt and sacrifice that
accompany such a dual life; the importance - and easy loss - of personal time
or what internist Catherine Chang calls “self-care” (page 334).
The anthology also touches on how women have changed the
practice of medicine in various ways, prompted by the growing realization, as
family practice physician Alison Moll puts it, "that I didn't have to
practice in the traditional way" (page 185) The authors write about the wisdom of setting
limits; training or working part-time or sharing a position with another woman;
and the constant face-off with decisions, especially those not normally
confronting an American man becoming a doctor.
One conclusion is evident before the reader is halfway through the book: there
are many approaches to becoming a fulfilled female physician including finding
one’s identity in the field. Implicit in
most of the essays and writings is the lament from obstetrician-gynecologist
Gayle Shore Mayer: "Where is the self ? There are pieces
of me everywhere", (page 275) recalling a similar cry from Virginia
Woolf's Orlando, another essentially female soul trying to find what Richard
Selzer has called "The Exact Location of the Soul". Several authors discover that female physicians have
unique gifts to offer their patients. As internist Rebekah Wang-Cheng writes, “I
am a better physician because I am a mother, and I know because of my
experiences as a physician that I am a better mother.” (page 151)

There are sections at the end devoted to a glossary for the lay reader,
resources for women (as of 2002), and generous notes about the contributors
(which section also serves as a useful index of each's contributions).

Several threads tie together this ambitious, beautifully
digressive reflection on eros and logos in the experience of illness and
the conduct of medicine and health care, which takes into account what a
complex striation of cultural legacies, social and political pressures, and
beliefs go into both. Framing his
reflections on the role of unknowing, altered states, inexplicable events,
desire, hope, love, and mystery in illness and healing is a fragmented,
poignant narrative of Morris’s own experience of watching his wife succumb to
the ravages of early Alzheimer’s.

Her
disease is one that leads both professional and intimate caregivers to the same
question: what do you do when there’s
nothing left for scientific medicine to do?
Conversations about palliative care are broadening, he points out, and
medical education is making more room for the kind of reflection the arts
invite and for spirituality as a dimension of illness experience and
caregiving. Guidance in such
explorations can be found in ancient literature, especially in the archetypes
provided by the Greek and Roman myths.
Morris makes astute and helpful use of his own considerable training in
literary studies to provide examples of how eros
and logos—complementary
contraries—have been conceived and embodied in a somewhat polarized culture and
how incomplete health care is when it doesn’t foster the capacity to dwell in
and with unknowing, possibility, indeterminacy, and mystery. Knowing the limits of scientific medicine
may, paradoxically, make it better.
Certainly it can help keep our engagements with illness—always
relational, always disruptive, most often to some degree bewildering—humane.

This engaging memoir describes Pearson's medical training at the University of Texas Medical Branch (UTMB) on
Galveston Island from 2009 to 2016. During these years her personal values
become clear, and she finds fault in her training, in medicine as
practiced in Texas, and even in her own errors in treating patients.
Having left a graduate writing program,
Pearson took a "postbac," a year of pre-med courses in Portland,
Oregon. She interviewed at medical schools "all over the country" and
writes satirically about them; she concludes "nothing out of Texas felt
quite right," having lived there and done her undergraduate work at
University of Texas at Austin. She's a Spanish speaker with a
working-class background. When her classmates provide the annual
“white-trash”-themed party, she wonders, “do I go as myself?” (p. 21).

Pearson's education continues on three tracks:
the formal UTMB courses in medicine, a simultaneous Ph.D. program at the
Institute for the Medical Humanities at the University of Texas, and her
volunteer work at the St. Vincent's Student Run Free Clinic. The Ph.D. program
is off-stage, not mentioned, but the St. Vincent's Clinic becomes pivotal
to her development as a doctor and a moral person.

As for medical school, she finds the relentless
"truths of biochemistry and anatomy" so reductive that the suffering
of people and surrounding politics seem "not to matter at all" (p.
70). Among the politics are: the lack of safety nets for poor people, the use
of uninsured (including prisoners) for students to practice on, failures
to extend Medicare, pollution (notably from the oil industry), losses of
charitable care, and income disparities that include crushing poverty for many.
Something of a rebel, she writes that medical school "felt like junior
high" (p. 44). She does enjoy the "clinical encounters" with
real patients.

St. Vincent's, by contrast, was “a relief.” Her
pages sparkle with her conversation with clinic patients, some
homeless, all poor, and all suffering. She reports--confesses, she even
says--her errors that had consequences for patients. She writes that errors are
an unavoidable part of medical education, but that it's wrong that they should routinely
happen to the poorest members of society.

Chapter 8 discusses depression, which she
felt after the second year. She writes about high rates of suicide among
medical students and doctors; indeed a close friend killed himself during the
"post-doc" year. Because some states require doctors to report
psychiatric care, some doctors avoid such care. This consequence “drives a suicide-prone
population away from the help we may need" (p.92).

The last two years are the rotations through
specialties: surgery, dermatology, trauma, rural medicine,
neurology, internal medicine, and so on. These are clearly and
insightfully described. In one case (internal medicine), she allows the reader
to see the irony of a doctor providing hair removal by laser, diet foods, and
Botox treatment for wrinkles, “a pure luxury transaction” (p. 183).

Pearson describes the storms, hurricanes, and
floods that hit Galveston Island, also the pollution from the oil industry that
causes a “cancer belt” along the Louisiana and Mississippi coasts (p. 104).
At last she finishes her program, understanding
that her identity is simultaneously a person, a physician, and a writer (p.
248).

This Way Madness Lies was published in partnership with London’s Wellcome
Collection for the exhibition “Bedlam: The Asylum and Beyond,” which ran from September 2016 - January 2017 and
was curated by Mike Jay and Bárbara Rodriguez Muñoz. It is a book that was
meant to accompany the exhibition, yet which, by virtue of the substantial text
and reproductions, can stand alone.

The book traces the history of treatment of
the mentally ill by following the colorful story of Bethlem Royal Hospital from
its antecedents in the Middle Ages up to the present. Its sway over the public imagination
evidenced by its appearance in everything from Jacobean Drama to “Sweeney
Todd,” Bedlam has truly attained archetypal status. An archetype, yet also a real functioning
hospital. Sections of the book entitled
“Madhouse,” Lunatic Asylum,” and “Mental Hospital” chronicle the facilities
designed respectively during the 17th/18th, 19th,
and 20th centuries, and explain how they reflect changing notions of
madness in each era.

The first structure was visually grand but
lacked a foundation, a metaphor for what was going on inside: “a façade of care
concealing a black hole of neglect” (p. 39).
It became a tourist attraction along the lines of the zoo, with nothing
preventing the public from gawking at and taunting the inmates. While its replacement gave the impression of
being more functional, conditions proved equally squalid. On the other hand, 19th-century
Europe and the United States saw asylum reforms, as well as the medicalization
of madness as an “illness” and the ascent of psychiatry as a branch of
medicine. Finally, in 1930, the
buildings still in use in Monks Orchard, a suburb of London, were constructed.

By contrast, we learn about treatments
elsewhere, most notably Geel, Belgium.
There, for centuries, as an alternative to being warehoused in
psychiatric hospitals, the mentally ill have been successfully boarding with
townspeople.